Abdominal ultrasound scans for diagnostic imaging of the liver

Ultrasound is a common first-line imaging investigation that uses sound waves to produce an image (sonogram) of the internal organs. It is easy, quick and cost-effective to perform and safe, non-invasive and generally painless for the patient. Abdominal ultrasound in particular visualises the hepatobiliary system. It is used to investigate abdominal pain, abnormal liver function tests, distension and jaundice, as well as to screen for hepatocellular carcinoma and abdominal aortic aneurysm. Ultrasound requests should include relevant clinical background information to ensure the patient receives the right test and help the sonographer rule out differential diagnoses. Before the test, patients should be given all available information and asked to fast for 6–8 hours, although clear fluids are permitted. The scan usually procedure takes 15–30 minutes but may be extended depending on pathology identified. The sonogram displays the comparative echogenicity of the liver and adjacent organs in real time. Increased echogenicity, a coarse echotexture and a saw-tooth liver edge are indicative of liver pathology. Ultrasound can also allow the assessment of the portal venous system to exclude portal vein thrombus or elevated portal velocities. Advanced clinical nurse practitioners can order ultrasounds in line with local hospital trust guidance, which may include Ionising Radiation Medical Exposure Regulations (IRMER) training.

Download Full-text

417 Initial Choice of Imaging Investigation for Patients Presenting with Acute Pancreatitis: Should MRCP Be First Line in Selected Patients?

British Journal of Surgery ◽

10.1093/bjs/znab259.050 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

L Yao ◽

C Briggs ◽

P Labib

Keyword(s):

Acute Pancreatitis ◽

Magnetic Resonance Cholangiopancreatography ◽

Abdominal Ultrasound ◽

Liver Function Tests ◽

First Line ◽

Retrospective Audit ◽

Surgical History ◽

History Of ◽

Line Imaging ◽

Initial Choice

Abstract Introduction Current guidelines for acute pancreatitis advocate abdominal ultrasound (AUS) as the first-line imaging investigation to identify if gallstones are the cause of pancreatitis. However, many patients have a history of cholecystectomy or present with known gallstones and deranged liver function tests (LFTs). In these patients, magnetic resonance cholangiopancreatography (MRCP) is indicated due to its higher sensitivity and specificity for detecting choledocholithiasis. Method This retrospective audit reviewed all consecutive patients who presented to the surgical assessment unit with acute pancreatitis over one month. Their past surgical history, bloods and imaging were reviewed. Results Of the 30 patients, seventeen (57%) had no previous cholecystectomy or known gallstones, nine (30%) had previous cholecystectomy and eight (27%) had known gallstones, seven (88%) of which presented with deranged LFTs. Of the seventeen patients who should have had AUS first (n = 17), thirteen (76%) had AUS first, none had MRCP first and four (24%) had computerised tomography (CT) first. Of the patients in whom MRCP was indicated first-line (n = 13), seven (54%) had AUS first, none had MRCP first, four (31%) had CT first and two (15%) went straight to endoscopic retrograde cholangiopancreatography having had recent outpatient MRCPs. In the seven patients in whom MRCP was indicated but AUS was performed first, six (86%) underwent subsequent MRCP. Conclusions MRCP should be considered the first line imaging investigation for patients presenting with acute pancreatitis and a history of cholecystectomy or known gallstones with deranged LFTs, as AUS rarely prevents the need for subsequent MRCP.

Download Full-text

EP.TU.439Falciform ligament torsion – a rare cause of the acute abdomen

British Journal of Surgery ◽

10.1093/bjs/znab311.057 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Shariq Sabri ◽

Adam O'Connor ◽

Maseera Solkar ◽

Amalia Ramzan ◽

Mamoon Solkar

Keyword(s):

Ct Scan ◽

Vascular Occlusion ◽

Normal Liver ◽

Abdominal Ultrasound ◽

Liver Function Tests ◽

Falciform Ligament ◽

Inferior Aspect ◽

Successful Recovery ◽

Upper Abdominal ◽

The Right

Abstract The falciform ligament attaches the liver to the anterior abdominal wall and diaphragm. Acute falciform ligament related pathology is rare. In this case report we present a case of acute fat necrosis related to the falciform ligament. A 53 year old women presented with acute upper abdominal pain localised to the right hypochondrium. He was tender to palpation in the same region with a positive Murphy’s sign. A provisional diagnosis of acute cholecystitis was made. Blood work revealed raised inflammatory markers but normal liver function tests. Abdominal ultrasound revealed no gallbladder pathology nor gallstones. Thus computed tomogram (CT) scan of the abdomen was performed, showing hyper-attenuation rim signal present within the inferior aspect of the falciform ligament consistent with local vascular occlusion. The patient was managed with intravenous antibiotics with liberal analgesia and went on to make a successful recovery. Only 10 cases have been reported in the literature related to falciform ligament necrosis. We present this unusual pathology encountered on our acute surgical take, to alert surgeons to this rare diagnosis and provide a review of the literature and provide detail of how such a pathology manifests on CT scan.

Download Full-text

Gallbladder Hydrops Associated with an Episode of Acute Liver Toxicity in the Adult: May It Be Considered a Surgical Emergency or Not?

Journal of Interdisciplinary Medicine ◽

10.1515/jim-2016-0027 ◽

2016 ◽

Vol 1 (2) ◽

pp. 180-182

Author(s):

Sorin Albu ◽

Septimiu Voidăzan ◽

Dragoș Popa

Keyword(s):

Liver Toxicity ◽

Abdominal Ultrasound ◽

Liver Function Tests ◽

Moderate Intensity ◽

Biliary Duct ◽

General Weakness ◽

Acute Toxic Hepatitis ◽

Immediate Surgery ◽

The Right ◽

Gallbladder Hydrops

Abstract Introduction: Gallbladder hydrops is an increase in the volume of the gallbladder without any inflammatory sign, bacterial infection or the presence of any abnormalities of the biliary ducts or of the gallbladder. Case presentation: A 52-year-old man presented at the Department of Internal Medicine complaining of moderate intensity pain in the right upper quadrant, low fever, fatigue, general weakness, symptoms stemming from an excessive intake of food (a meal abundant in animal proteins, fats, and alcohol) which appeared following a 6-week period of food restriction. On examination, the patient presented a globular abdomen, sensitive to deep palpation in the right upper quadrant, the liver and spleen being impalpable. Blood tests performed on admission showed liver-specific pathological changes. Abdominal ultrasound revealed hepatomegaly with homogeneous echostructure, slightly increased echogenicity with rear attenuation, with no focal images, intrahepatic biliary duct dilatation, or dilated suprahepatic veins. The gallbladder looked dropsical, with slender walls, with images of hyperechoic infundibular calculi with a posterior shadow cone, the largest having 14 mm. The portal vein and bile duct were normal in appearance. Conclusions: Gallbladder hydrops is a disorder commonly seen in children. Its occurrence in adults is uncommon, moreover since it occurs simultaneously with an episode of acute toxic hepatitis. Surgery for this patient was possible only after normalization of liver function tests, on admission there being no subjective complaints of marked intensity that required immediate surgery.

Download Full-text

SP10.1.4 COVID as a driver of innovation: getting the right patient to the right place at the right time. A novel Registrar-led approach to minimising unnecessary footfall in the Surgical Assessment Unit of a District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab361.177 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Emma L. Court ◽

Nicola A. Lennon ◽

Anas Zarka ◽

Megan Pryor ◽

Susan Lawrence ◽

...

Keyword(s):

Nurse Practitioners ◽

Cost Savings ◽

Cost Effective ◽

District General Hospital ◽

Service Development ◽

Telephone Triage ◽

Assessment Unit ◽

Outcome Comparison ◽

Impact Patient Care ◽

The Right

Abstract Aim To give shielding Registrars opportunities to innovate and lead service development through telephone triage of Surgical Assessment Unit (SAU) referrals from General Practitioners and Nurse Practitioners. Prior to the COVID pandemic, referrals were taken by Nurse Coordinators. Increasing call volumes put pressure on the department and disrupted clinical duties. Furthermore, referrers often expressed difficulties in contacting SAU staff. Methods During the study, referral calls were diverted for triage by the hospital switchboard. Three outcomes were offered: Clinical advice, ‘Hot Clinic’ (HC) appointment or urgent SAU review. Prospective referral data (15/6-31/7/2020) and retrospective non-triage data (15/6-1/7/2019) were gathered. Triage effects were measured by outcome comparison with non-triage data and the associated financial implications calculated. Stakeholder feedback questionnaires were distributed. Results Non-triage data showed 56% of patients reviewed in SAU were sent home and 44% admitted, compared to 23.6% and 28.1% of referrals during the 2020 study period. Furthermore, 28.4% of admissions were avoided by triage. Only 3.1% of triaged patients presented to Emergency Department within 7 days of the triage conversation. Almost half of these had been reviewed in SAU following triage and discharged the same day. HC availability was limited during the triage study. In view of reduced admissions and overall cost savings of £8330.62/week, expanding these clinics may prove cost neutral. Triage was universally popular with stakeholders. Data will inform future development of Urgent and Emergency Care at our hospital. Conclusions Traditional ways of working should be challenged. Novel approaches can be cost effective & positively impact patient care.

Download Full-text

Screening for aneurysms of the abdominal aorta using a simple screening device

The Ultrasound Journal ◽

10.1186/s13089-020-00192-5 ◽

2020 ◽

Vol 12 (1) ◽

Author(s):

J. W. Brakel ◽

T. A. Berendsen ◽

P. M. C. Callenbach ◽

J. van der Burgh ◽

R. J. Hissink ◽

...

Keyword(s):

Negative Predictive Value ◽

Sensitivity And Specificity ◽

Abdominal Aorta ◽

Predictive Value ◽

Cost Effective ◽

Abdominal Ultrasound ◽

Predictive Values ◽

Bladder Scan ◽

Health Council ◽

Screening Device

Abstract Introduction Several countries advocate screening for aneurysms of the abdominal aorta (AAA) in selected patients. In the Netherlands, routine screening is currently under review by the National Health Council. In any screening programme, cost-efficiency and accuracy are key. In this study, we evaluate the Aorta Scan (Verathon, Amsterdam, Netherlands), a cost-effective and easy-to-use screening device based on bladder scan technology, which enables untrained personnel to screen for AAA. Methods We subjected 117 patients to an Aorta Scan and compared the results to the gold standard (abdominal ultrasound). We used statistical analysis to determine sensitivity and specificity of the Aorta Scan, as well as the positive and negative predictive values, accuracy, and inter-test agreement (Kappa). Results Sensitivity and specificity were 0.86 and 0.98, respectively. Positive predictive value was 0.98 and negative predictive value was 0.88. Accuracy was determined at 0.92 and the Kappa value was 0.85. When waist–hip circumferences (WHC) of > 115 cm were excluded, sensitivity raised to 0.96, specificity stayed 0.98, positive and negative predictive value were 0.98 and 0.96, respectively, accuracy to 0.97, and Kappa to 0.94. Conclusion Herein, we show that the Aorta Scan is a cost-effective and very accurate screening tool, especially in patients with WHC below 115 cm, which makes it a suitable candidate for implementation into clinical practice, specifically in the setting of screening selected populations for the presence of AAA.

Download Full-text

Facing Death: Attitudes toward Physician-Assisted End of Life among Physicians Working at a Tertiary-Care-Hospital in Israel

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18126396 ◽

2021 ◽

Vol 18 (12) ◽

pp. 6396

Author(s):

Keren Dopelt ◽

Dganit Cohen ◽

Einat Amar-Krispel ◽

Nadav Davidovitch ◽

Paul Barach

Keyword(s):

End Of Life ◽

Tertiary Care Hospital ◽

Human Life ◽

Tertiary Care ◽

Terminally Ill ◽

Background Information ◽

Care Hospital ◽

Medical Assistance In Dying ◽

Terminally Ill Patients ◽

The Right

The demand for medical assistance in dying remains high and controversial with a large knowledge gap to support optimal patient care. The study aimed to explore physicians’ attitudes regarding euthanasia and examine the factors that related to these attitudes. We surveyed 135 physicians working at a tertiary-care hospital in Israel. The questionnaire was comprised of demographic and background information, DNR procedure information, encounters with terminally ill patients, familiarity with the law regarding end-of-life questions, and Attitudes toward Euthanasia. About 61% agreed that a person has the right to decide whether to expedite their own death, 54% agreed that euthanasia should be allowed, while 29% thought that physicians should preserve a patients’ life even when they expressed the wish to die. A negative statistically significant relationship was found between the level of religiosity and attitudes toward euthanasia. The physicians’ attitudes towards euthanasia are quite positive when compared to other countries. The data shows a conflict of values: the sacredness of human life versus the desire to alleviate patients’ suffering. The Coronavirus-19 outbreak reinforces the importance of supporting physicians’ efforts to provide ethical and empathic communication for terminally ill patients. Future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to end-of-life requests.

Download Full-text

Persistently raised aspartate aminotransferase (AST) due to macro-AST in a rheumatology clinic

Diagnosis ◽

10.1515/dx-2014-0065 ◽

2015 ◽

Vol 2 (2) ◽

pp. 137-140 ◽

Cited By ~ 2

Author(s):

Wycliffe Mbagaya ◽

Joanne Foo ◽

Ahai Luvai ◽

Claire King ◽

Sarah Mapplebeck ◽

...

Keyword(s):

Liver Function ◽

Aspartate Aminotransferase ◽

Normal Liver ◽

Abdominal Ultrasound ◽

Liver Function Tests ◽

Analytical Investigation ◽

Normal Liver Function ◽

Rheumatology Clinic ◽

History Of ◽

Liver Biopsies

AbstractMacrocomplexes between immunoglobins and aspartate aminotransferase (macro-AST) may result in persistently increased AST concentration. The presence of macro-AST in patients has been implicated in unnecessary investigations of abnormal liver function tests. We report the case of a 44-year-old female who presented to the rheumatology clinic with a 12-months’ history of constant widespread pain affecting her limbs and was found to have an elevated AST concentration. Further information from her GP revealed a 14-years’ history of elevated AST with otherwise normal liver function. Previous abdominal ultrasound and two liver biopsies carried out 2 years apart were normal. This prompted further analytical investigation by the biochemistry department which identified macro-AST as the cause. This case illustrates that persistently raised isolated AST concentration with no other abnormal indices may warrant macroenzyme analysis potentially avoiding unnecessary invasive investigations.

Download Full-text

ERP benefits capability framework: orchestration theory perspective

Business Process Management Journal ◽

10.1108/bpmj-11-2015-0162 ◽

2018 ◽

Vol 24 (1) ◽

pp. 266-294 ◽

Cited By ~ 6

Author(s):

Amgad Badewi ◽

Essam Shehab ◽

Jing Zeng ◽

Mostafa Mohamad

Keyword(s):

Cost Effective ◽

Organizational Capabilities ◽

Erp Implementation ◽

Content Type ◽

Quantitative Studies ◽

Financial Perspective ◽

Complementary Resources ◽

Benefits Realization ◽

Research Questions ◽

The Right

Purpose The purpose of this paper is to answer two research questions: what are the ERP resources and organizational complementary resources (OCRs) required to achieve each group of benefits? And on the basis of its resources, when should an organization invest more in ERP resources and/or OCRs so that the potential value of its ERP is realised? Design/methodology/approach Studying 12 organizations in different countries and validating the results with 8 consultants. Findings ERP benefits realization capability framework is developed; it shows that each group of benefits requires ERP resources (classified into features, attached technologies and information technology department competences) and OCRs (classified into practices, attitudes, culture, skills and organizational characteristics) and that leaping ahead to gain innovation benefits before being mature enough in realising a firm’s planning and automation capabilities could be a waste of time and effort. Research limitations/implications It is qualitative study. It needs to be backed by quantitative studies to test the results. Practical implications Although the “P” in ERP stands for planning, many academics and practitioners still believe that ERP applies to automation only. This research spotlights that the ability to invest in ERP can increase the innovation and planning capabilities of the organization only if it is extended and grown at the right time and if it is supported by OCRs. It is not cost effective to push an organization to achieve all the benefits at the same time; rather, it is clear that an organization would not be able to enjoy a higher level of benefits until it achieves a significant number of lower-level benefits. Thus, investing in higher-level benefit assets directly after an ERP implementation, when there are no organizational capabilities available to use these assets, could be inefficient. Moreover, it could be stressful to users when they see plenty of new ERP resources without the ability to use them. Although it could be of slight benefit to introduce, for example, business intelligence to employees in the “stabilizing period” (Badewi et al., 2013), from the financial perspective, it is a waste of money since the benefits would not be realised as expected. Therefore, orchestrating ERP assets with the development of organizational capabilities is important for achieving the greatest effectiveness and efficiency of the resources available to the organization. This research can be used as a benchmark for designing the various blueprints required to achieve different groups of benefits from ERP investments. Originality/value This research addresses two novel questions: RQ1: what are the ERP resources and OCRs required to achieve the different kinds of ERP benefits? RQ2: when, and on what basis, should an organization deploy more resources to leverage the ERP business value?

Download Full-text

Complicated EBV infection in a healthy child

BMJ Case Reports ◽

10.1136/bcr-2020-241099 ◽

2021 ◽

Vol 14 (3) ◽

pp. e241099

Author(s):

Hugo Teles ◽

Teresa Brito ◽

Joana Cachão ◽

Susana Parente

Keyword(s):

Healthy Child ◽

Acalculous Cholecystitis ◽

Abdominal Ultrasound ◽

Good Prognosis ◽

Left Ventricular ◽

Acute Acalculous Cholecystitis ◽

Cervical Lymph Nodes ◽

Barr Virus ◽

Ebv Infection ◽

The Right

The Epstein-Barr virus (EBV) is highly prevalent throughout the population. Although in most cases, the infection has a good prognosis, it can cause severe complications. We report a case of a healthy child with a primary EBV infection that evolved with two rare complications. She first presented in the emergency room with fever and sore throat, and was diagnosed with tonsillitis and medicated with antibiotic. She returned 7 days later for fatigue, vomiting and abdominal pain. The examination revealed tonsillitis, swollen cervical lymph nodes and pain in the right hypochondrium. An abdominal ultrasound was performed, compatible with acute acalculous cholecystitis. She was admitted in the paediatric nursery and medicated with intravenous antibiotics. The EBV serology revealed primary infection. Two days later, she developed cardiogenic shock and had to be transferred to an intensive care unit under mechanical ventilation and inotropics. She was discharged 12 days later, keeping a moderate left ventricular dysfunction.

Download Full-text